Healthcare Client Master

HEALTHCARE CLIENT MASTER

Client Identification

Client Name:

Date of Birth:    Gender: Male Female Other Prefer not to say

Emergency Contact

Insurance Information

Medical History

Consent for Treatment & Authorizations

By signing below, I authorize the health care providers affiliated with this practice to provide evaluation, diagnostic procedures, medical and surgical treatment, and routine ancillary services as deemed necessary by the treating clinician. I acknowledge that no guarantees have been made to me as to the results of any treatment.

I understand the potential risks and benefits of proposed treatments and that I retain the right to withdraw consent at any time, except to the extent that actions have already been taken in reliance on this consent.

Financial Responsibility & Assignment of Benefits

I accept financial responsibility for services provided. I authorize my insurance benefits to be paid directly to the provider and agree to cooperate in obtaining payment from insurance carriers. I am responsible for copayments, deductibles, co-insurance, and services not covered by my insurer. If payment is not received from my insurer, I agree to be responsible for the remaining balance.

Release of Information & Medical Records Authorization

I authorize release of protected health information to my insurance carrier and to other health care providers for treatment, payment and health care operations. I authorize the provider to receive and disclose medical information necessary for these purposes. This authorization includes but is not limited to diagnosis, treatment notes, test results, and billing information.

I understand that I may revoke this authorization at any time by submitting written notice, except where the provider has already acted in reliance on the authorization. I understand that information disclosed pursuant to this authorization may be redisclosed by the recipient and may no longer be protected by federal privacy rules.

Privacy Practices (HIPAA) Acknowledgment

I acknowledge that I have received or been offered a copy of the provider's Notice of Privacy Practices describing how my protected health information may be used and disclosed and my rights regarding that information. I understand my rights to request restrictions and confidential communications as permitted by law.

Authorization Duration

This Healthcare Client Master record and the authorizations contained herein shall remain in effect until revoked in writing by the client or their authorized representative or until the following expiration date:

Certification

I certify under penalty of law that the information provided on this form is true, complete, and correct to the best of my knowledge. I understand that providing false information may affect my eligibility for services and/or may result in civil or criminal liability.

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